Indication-first implementation of uniportal video-assisted thoracic surgery segmentectomy for early-stage non-small cell lung cancer

Following the results of the JCOG0802/WJOG4607L and Cancer and Leukemia Group B (CALGB) 140503 trials, segmentectomy and sublobar resection have become standard treatment options for peripheral early-stage non-small cell lung cancer (NSCLC) measuring 2 cm or less (1,2). Consequently, performing anatomic segmentectomy in a less invasive manner while preserving oncologic radicality is a major challenge in contemporary thoracic surgery. Uniportal video-assisted thoracic surgery (VATS), first reported by Gonzalez-Rivas et al. in 2012, has been widely adopted as a minimally invasive approach that evolved from reduced-port surgery (3). Although reducing the number of incisions may offer benefits in terms of postoperative pain (4-8) and recovery (7-10), uniportal VATS requires the manipulation of multiple instruments and the camera through a single incision. This creates technical challenges, particularly during segmentectomy, regarding exposure, vascular and bronchial management, and intersegmental plane division. Concerns regarding the quality and extent of lymph node dissection persist (10-12).

Suzuki et al. systematically describe a series of technical refinements designed to facilitate safe and reproducible uniportal VATS segmentectomy. These include preoperative simulation using three-dimensional computed tomography (13), a vein-first strategy using the pulmonary veins as anatomical landmarks, identification of the intersegmental plane with indocyanine green fluorescence, and confirmation of the target bronchus. Their report provides a practical roadmap for implementing uniportal VATS segmentectomy not merely as “small-incision surgery” , but as a planned and reproducible anatomic procedure.

Although uniportal VATS offers the advantage of being minimally invasive, oncologic radicality and patient safety must remain the highest priorities in lung cancer surgery. While fewer incisions are desirable, surgeons should not hesitate to convert to multiport VATS or thoracotomy if adequate surgical margins, appropriate lymph node evaluation, or safe vascular and bronchial management cannot be ensured.

Suzuki et al. provide a valuable roadmap for implementing uniportal VATS segmentectomy in appropriately selected patients. However, the future of uniportal segmentectomy should be defined not merely by expanding its indications, but rather by refining patient selection, ensuring adequate surgical margins and lymph node evaluation, and selecting the safest approach for each individual case.

Acknowledgments

The authors used ChatGPT for language editing and manuscript formatting checks. The authors reviewed and edited the content and take full responsibility for the final manuscript.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0047/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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